The Poetics of Therapeutic Practice: Motivational Interviewing and the Powers of Pause

Abstract

Motivational interviewing (MI) is an increasingly prominent behavioral therapy that draws from and claims to synthesize two American therapeutic traditions long thought to be antithetical—“client-centered” and “directive” approaches. This paper proposes that MI achieves its hallmark “client-centered directiveness” through the aesthetic management of the therapeutic encounter, and more particularly, through MI practitioners’ marked use of silence. Drawing on data collected during the ethnographic study of MI trainings and the formal analysis of video-recorded MI sessions that are commonly used as models in such trainings, we identify three patterns of pause that regularly fall at specific grammatical junctures within seasoned MI practitioners’ turns-at-talk. We demonstrate how these pauses allow MI practitioners to subtly direct the conversation while simultaneously displaying unequivocal signs of client-centeredness. In other words, we show how and explain why the poetics of pause matter to MI. In presenting this case, we more generally highlight practice poetics—that is, the aesthetic management of the style and delivery of a professional message with a particular practical aim in mind—suggesting that this is a central if under-appreciated aspect of therapeutic practices.

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Notes

  1. 1.

    Quite appropriately, medical anthropologists critically attend to the monikers clinical practitioners use to denote (and indeed interpellate) the people with whom they work, pointing out—for instance--how the term “patient” evokes medical interactions and institutions, whereas “client” and “consumer” index consumptive capitalism. While the genealogy of the term “client” in American psychotherapy is beyond the scope of this paper, it is important to note that it has roots in Rogers’ central formulation of his approach as “client-centered therapy,” a term which he insisted could be used interchangeably with “person-centered therapy” (see Rogers 1986). In prominent MI texts, the term “client” is most common, which may index the wide range of professional fields in which MI is currently practiced, as well as its Rogerian roots. We use the term “client” here as a native term, acknowledging both its clinical and cultural history, and particular resonance in a politico-therapeutic era in which American counseling approaches, like MI, are branded, marketed, and differentially valued.

  2. 2.

    Notably, Skinner—unlike Rogers—was not a practicing psychotherapist. However, he was keenly interested in the practical implications of his theory of behavior, especially in the field of education. As in therapy, Skinner argued, the practitioner’s job is “to implant or shape behavior—to build it up and strengthen it, rather than to find it already in the student and draw it out [as Rogers claims]” (Kirschenbaum et al. 1989, p. 118).

  3. 3.

    Published clinical research across these terrains of MI practice, which focuses on treatment efficacy measured in terms of specific client outcomes, includes examinations of MI in substance abuse treatment (e.g., Burke et al. 2004; Hettema et al. 2005; Miller et al. 1993), mental illness (e.g., Angus and Kagan 2009), primary care medicine (e.g., Emmons and Rollnick 2001; Rollnick et al. 2012), intimate partner violence and couples counseling (Cordova et al. 2001; Kistenmacher and Weiss 2008; Musser and Murphy 2009), corrections and parole (McMurran 2009), and HIV risk prevention in the U.S. (Picciano et al. 2001), Northern Europe (e.g., Baker et al. 1993), and sub-Saharan Africa (Cornman et al. 2008), smoking cessation with Chinese Americans (e.g., Wu et al. 2009), and water purification interventions in Zambia and Malawi (Thevos et al. 2002).

  4. 4.

    In studying the three editions of the key text on motivational interviewing, which appeared successively in 1991, 2002, and 2013, one finds Rogers increasingly cited and Rogerian terms becoming more prominently woven through the text. Even the subtitles of each edition arguably signal the shift from a more explicitly behaviorist orientation to a more client-centered one: Preparing people to change addictive behaviors (1st ed.), Preparing people for change (2nd ed.); Helping people change (3rd ed.).

  5. 5.

    The extraordinary debates between Rogers and Skinner unfolded before a cold-war American audience that was highly suspicious of Skinner’s theoretical abandonment of the sovereign subject destined to craft his own ends. And if Rogers’ post-Freudian focus on fully realizable interiority may have initially discomfited a pre-Oprah public (see Lowney 1999), the terms of “self-actualization” eventually came to permeate contemporary popular American psychological discourse. So although many psychotherapists continue to practice in line with behaviorist principles, the fundamentals of their practice are arguably far less culturally legible and acceptable than those of their humanist counterparts.

  6. 6.

    Considering that the rules and conventions of speaking that MI cultivates in its practitioners are ones clearly rooted in Standard American English (SAE), with standardization being understood as a hegemonic process of institutional maintenance and naturalization within a given linguistic community (see Silverstein 1996), one of MI’s bolder and more questionable claims is that the method “speaks” to a global audience. Here, we focus on the formulation, training, and practice of MI among American English speakers, understanding the meaning and effects of MI’s signature pauses will differ as it travels, and indeed would be an especially fruitful terrain for anthropological research on cross-cultural applications and extensions of American psychotherapy.

  7. 7.

    Poetics comprise the formal features of a spoken or written text, including intonation, turn-taking, parallelism, meter, and pause. Focused on the form of a message, rather than its semantic content, poetics “animates” that content in any number of ways (Jakobson 1960; see also Goodwin 1981; Holmes and Janet 1990; Schiffrin 1987; Stubbe and Holmes 1995). The idea of “practice poetics” builds on Jakobson’s insight, which has been elaborated by a number of linguistic anthropologists, that poetics characterize many kinds of speech events, including everyday dyadic conversation (e.g., Bauman and Briggs 1990; Silverstein 1984), political discourse (e.g., Lempert and Silverstein 2012; Mendoza-Denton, 1995; Silverstein 2003) and legal discourse (e.g., Matoesian 1993). Yet poetics are also central to establishment and performance of particular genres of speaking, including professional registers (see, for example, Cicourel 1982), because they are a primary way speakers call attention to and distinguish their speech, if in an implicit way.

  8. 8.

    Building on Hymes’ (1974) and Gumperz’s (1962) foundational proposal that there are rules for how and when one speaks that must be followed in order to be recognized as a member of a given speech community, we suggest that there are particular aesthetic markers of MI as a professional register, hence our particular attention to style.

  9. 9.

    The degree to which practice poetics are readily evident to the lay listener differs across schools of psychotherapy, with some practices seeming obviously stylized (think of the psychoanalyst’s marked degree of silence) and others seeming more akin to everyday speech. Furthermore, while some professional cultures have an explicit discourse about their linguistic practices, which is systematically transmitted to novice practitioners and/or is carefully delineated by psychotherapy process researchers working within that tradition, other professional cultures rely on more implicit, osmotic modes of cultivating and transmitting their practice poetics.

  10. 10.

    The conversational strategies used in medical interviews have been studied along somewhat similar lines. Ainsworth-Vaugh (1992), for example, classifies strategies for introducing topics in doctor/patient conversations as either unilateral or reciprocal, with male doctors using controlling unilateral strategies relatively more often (see also, Fisher and Groce 1990). Relative to client-centered approaches to psychotherapy, directive approaches might be viewed as relying more heavily on unilateral topic introductions through using established agendas and other directive techniques. However, as the case of MI demonstrates, the avoidance of unilateral topic transitions does not necessarily mean that clinicians are not actively working to maintain control of the clinical interaction.

  11. 11.

    Researchers of behavioral interventions tend to view therapist language as a series of speech acts such as questions, reflections, or advisements (e.g., Stiles et al. 1988) or “speech content” (e.g., Luborsky et al. 1982) to the exclusion of the poetic features of therapist language. For an interesting exception, see Elkin et al. (n.d.) measure of “therapist responsiveness” in cognitive behavior therapy and interpersonal psychotherapy, which includes a number of poetic features.

  12. 12.

    In the psychotherapy research literature, the term “active ingredient” generally refers to actions by the therapist, which are believed to affect the outcome of an intervention (e.g., Elkin et al. 1988). A growing literature addresses the extent to which the unique, hallmark actions characteristic of a particular intervention or factors common across many interventions are actually responsible for client outcomes (e.g., Ahn and Wampold 2001). We use the term “active ingredient” somewhat differently here, to point to the way therapy-specific poetics—including the uses of pause demonstrated here—actively shape how clients and clinical researchers alike perceive a therapy as more or less effective.

  13. 13.

    Some of these analyses suggest that sustained gaps between professional and client speech are ideologically and functionally linked to the therapeutic ideal of client reflectiveness. By contrast, consider Sabina Perrino’s (2002) discussion of latching and overlap in Senegalese ethnomedical encounters, which mitigate against sustained lapses of speech between patient and practitioner turns-at-talk. A concern that silence at turn boundaries might be (mis)interpreted as a sign of disjuncture is reflected in the field of American palliative care, where some have been careful to distinguish between productive and unproductive silence (see for example, Back et al. 2009).

  14. 14.

    Pertinent here are questions of which elements of speech are relatively available to speaker awareness, with many arguing that the presupposing elements of speech are more readily recognizable than the entailing (Silverstein 2001; cf. Carr 2010). These will be more fully addressed in the conclusion.

  15. 15.

    As a treatment fidelity tool, the MITI plays a central role in on-the-ground MI training: trainers ask novices to audio record their MI sessions with clients and use the MITI to code and evaluate the recordings and provide constructive feedback. These trainers use the MITI, as intended by its developers, to assess “how well or poorly is a practitioner using motivational interviewing” (Moyers et al. 2009, p. 1).

  16. 16.

    Note that this is a significant departure from insight-oriented therapies, in which the practitioner’s focus is to get the client to say what they truly believe (see Carr 2010, 2013).

  17. 17.

    MI’s investment in the performativity of therapeutic language arguably intersects with the development of the concept of “expressed emotion” in psychological anthropology, particularly the exploration of the therapeutic possibilities of particular sorts of co-constitutive dialogues (Capps and Ochs 1995) and the potentially damaging effects of less engaged or interactive modes of communication (Jenkins 1991; Wilce 1998).

  18. 18.

    In fact, some MI insiders refer, usually half jokingly, to this text as the “MI Bible,” and some tell conversion narratives that are plotted from their first encounter with it.

  19. 19.

    Furthermore, in interviews and conversations, Miller and other lead MI proponents not infrequently point to research done by Rogers’ students (Truax 1966; see also Truax and Carkhuff 1967), who examined the “directive” elements of Rogers’ own psychotherapeutic practice. Their point is that even the most client-centered engagements have directive elements, and that philosophical purism is impractical, if not impossible. They also imply that in making conscious and explicit the inherently directive elements of the psychotherapeutic encounter, MI represents an advancement of Roger’s method.

  20. 20.

    In the latest edition of their widely read text, Miller and Rollnick emphasize “guiding” as a middle ground in a “continuum of styles” between the implicitly Rogerian extreme of following and the implicitly behaviorist extreme of “directing” (see 2013, p. 4–5).

  21. 21.

    While clinical theorists across traditions have recognized the importance of silence to the therapeutic encounter (Lane et al. 2002; Langs 1982; Reik 1926; Rogers 1942), and there has been work on the meaning of patients’ silence (Gale and Sanchez 2005; Levitt 2001a, b), clinical process researchers do not commonly empirically examine pause and other stylistic features of expert psychotherapeutic registers (for important exceptions see Cook 1964; Gans and Counselman 2000; Wickman 1999; Wickman and Campbell 2003).

  22. 22.

    For instance, in his study of dinner conversations, Watts (1997) argued that participants use silence in status negotiations to the control of possible interpretations of the legitimacy of what has been said and by whom.

  23. 23.

    Contrary to Basso’s claim that “the form of silence is always the same” (1970, p. 215), we work to distinguish different forms and patterns of silence, suggesting a correlate range of possible meanings and effects.

  24. 24.

    Jakobson distinguished the metalingual function and the poetic function of language, while maintaining that poetics are a way that speakers mark their texts as a specific genre by manipulating its formal features in regular and recognizable ways. Mannheim (1986) suggests that the implicit and performative nature of the poetic function makes it far less accessible to speaker awareness than the explicit propositional work of the metalingual function (see also Pressman 1994). However, some expert practices, like MI, are predicated on cultivating professional consciousness of the poetic dimensions of speech (see Carr 2010). Furthermore, the distribution of metalinguistic awareness is as much a political matter as a psycholinguistic one (see Carr 2011, Chap. 6), as indicated by the difference between MI trainers’ attention to poetics and the MITI’s abstraction of them.

  25. 25.

    While acknowledging that OARS are derived from client-centered therapy, Miller and Rollnick say that OARS, when “woven together,” constitute “the fabric” of MI (2002, p. 65).

  26. 26.

    Many MI trainers ask that those playing interviewees come up with a problem from their own lives for the interviewer to handle. They reason that this makes the exercise far more realistic, often adding that people tend to assume the identity of the “client from hell” when they role play.

  27. 27.

    Ki explained that one could make a question sound like (a more efficacious) reflection by simply avoiding raising one’s voice at the end of the sentence. The following section will further discuss ideological relationship and relative performance of Open question and reflections.

  28. 28.

    This metaphor also supports Ki’s labor as a trainer and the MI training industry more generally, for as Miller and another co-author write, “The real learning is in doing, and that requires ongoing practice with feedback” (Arkowitz and Miller 2008, p. 20).

  29. 29.

    In modeling an interchange that includes the tag question, “did I get that right?” Ki circumvents a general principle of MI: that is, to avoid Closed-ended questions, which by inviting simple yes or no responses, potentially truncate the therapeutic dialogue. In this case, Ki clarifies that the Closed-ended tag question has an overriding value and function: that is, to project uncertainty that he, as the practitioner, has yet to accrue a full understanding of the client and has the desire to do just that.

  30. 30.

    This is consistent with the current process research of MI, which suggests that reflections facilitate more change talk (Catley et al. 2006), which is in turn associated with changed behavior (Amrhein et al. 2003; Moyers et al. 2007).

  31. 31.

    Notably, none of these very marked pauses hit the two to three second mark that Ki suggested to his trainees, which are extremely lengthy by almost any standard.

  32. 32.

    Although the first author attended many MI trainings and interviewed dozens of experienced MI trainers across the United States, and accordingly developed the strong intuitive sense that Ki’s use of silence was characteristic of the MI speech community, a more formal analysis was needed to confirm this intuition.

  33. 33.

    The MITI has been especially used in MI coaching, an individualized component of advanced MI training. Coaches commonly work in conjunction with trainers, and a large part of their work involves evaluating trainees’ audio-recorded MI sessions with actual clients. The MITI provides these coaches a systematic way to both code and evaluate these sessions in line with criteria set forth by MI authorities.

  34. 34.

    Using these conventions, the second author produced transcripts of “Rounder” and “Ponytail” using the transcription assisting software Express Scribe, which has a feature that allows the transcriber to estimate the length of pauses with reasonable accuracy (i.e., within a tenth of a second). Both authors reviewed these transcripts independently, checking them against the film for accuracy. Some corrections were made to the transcripts, and disagreements about how to transcribe particular utterances were discussed and resolved. After reviewing and refining the technical transcripts, the authors independently examined the transcripts to identify possible patterns in the use of pause. After this initial review, the first author identified patterns involving pauses, which were confirmed by the second author’s independent examination. All the examples were checked again in a third round review by both authors.

  35. 35.

    Seven MITI coded reflections were eliminated because they were constituted by fewer than five words, arguably allowing little chance for the practitioner to engage in the poetics of pause.

  36. 36.

    This tendency is especially prominent when extending a turn-at-talk when an interlocutor has failed to take their turn. So whereas pauses before conjunctions can be used as a conversational device to manage turn-taking, MI’s intra-turn post-conjunction pauses clearly have another function and are noticeable precisely because they deviate from conventional ways of speaking.

  37. 37.

    The fact that Miller and Moyers repeat this invitation in single turns at talk ultimately suggests that their dysfluency, like their pausing, is carefully managed.

  38. 38.

    Although the MITI explicitly codes for the “content” of what MI practitioners say, assigning particular speech acts to relevant categories (i.e., “reflection,” “open-ended question,” “Mi-consistent”), it offers no systematic way to account for the poetic features of practitioner speech. If the poetics of practitioner speech are addressed at all in the MITI, it is through their implicit inclusion in an overall “gestalt impression” of the interview, which is coded in a second pass of the transcript. According to the MITI coding manual, the gestalt impression is oriented to the “spirit” of the interview, and more particularly to the extent to which the practitioner demonstrates each of the valued dimensions of MI practice: including how “collaborative” or client-centered as well as how successfully “directive” he or she is. At the same time that it marks what it calls “spirit” and what we call “style” of the motivational interview, the MITI manual provides no further guidelines for differentiating these two elements of interviewer speech, nor does it elaborate what kinds of stylistic features of language contribute to the “gestalt” of the MI session.

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Acknowledgments

The authors acknowledge and thank Marianne Brennan, Julie Chu, Jennfier Cole, and Constantine Nakassis for their comments and contributions to this work.

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Correspondence to E. Summerson Carr.

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Carr, E.S., Smith, Y. The Poetics of Therapeutic Practice: Motivational Interviewing and the Powers of Pause. Cult Med Psychiatry 38, 83–114 (2014). https://doi.org/10.1007/s11013-013-9352-9

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Keywords

  • Poetics
  • Pause
  • Psychotherapy
  • Motivational interviewing
  • Behaviorism
  • Client-centered therapy